Mohan, et al: Stroke volume variation

Stroke Volume Variation Directed Versus

Conventional Fluid Therapy for
Postoperative Acute Kidney Injury after
Percutaneous Nephrolithotomy - A
Randomized Pilot Study
Aparna Mohan1 , Michell Gulabani2 , Asha Tyagi3 , Jubin Jakhar1 , Mahendra Kumar4
ORIGINAL ARTICLE

ABSTRACT
Background: Percutaneous nephrolithotomy (PCNL) surgery may be associated with postoperative Acute
Kidney Injury (AKI). Commonest intraoperative risk factors for postoperative AKI include hypotension
and hypoperfusion. Intravenous fluids are administered during surgery to optimize intravascular status
and thus prevent hypotension. Conventionally, intravenous fluids are administered during surgery using
pre-calculated volumes based on maintenance needs. Alternatively, goal-directed fluid therapy using
Stroke Volume Variation (SVV) can be used to decide the volume of intravenous fluids. We compared
early postoperative AKI following intraoperative use of conventional (group C, n=15) versus SVV directed
fluid therapy (group S, n = 17) in patients undergoing PCNL surgery. Methods: This double-blinded
pilot study involved 32 adult patients, randomised to two groups according to type of intraoperative
fluid therapy (group C or group S). Postoperative AKI was diagnosed as per KDIGO guidelines. Results:
Incidence of early postoperative AKI was clinically higher for group S, though statistically similar, as
compared to group C (47.1% versus 26.7%) (P = 0.234). Postoperative increase in eGFR, and 24-hour
urine output were clinically greater for group S (P > 0.05). Volume of intraoperative fluids infused was
significantly lesser for group S (P = 0.000). The incidence of hypotension and requirement of vasopressor
to maintain blood pressure was clinically lesser, though statistically similar for group S as compared to
group C (P = 0.659). Conclusions: There appears to be a clinical trend of greater incidence of AKI with
use of SVV guided therapy despite better intraoperative hemodynamic stability and greater improvement
in postoperative urine output and eGFR in the first postoperative day.

KEY WORDS: Percutaneous nephrolithotomy, Acute kidney injury, Fluid therapy, General anesthesia,
Blood pressure.

Introduction
Percutaneous nephrolithotomy (PCNL) is a mini-
Access this article online mally invasive surgery carried out for kidney stone
Quick Response Code: removal and restoration of renal function. It is a
treatment of choice for managing large, multiple or
complex renal stones. [1] Though it is a surgery aiming
for renal function restoration, it can paradoxically
be associated with significant risk of postoperative
Website: www.jmsh.ac.in
Acute Kidney Injury (AKI). [2,3] There is only some
Doi: 10.46347/jmsh.v9i1.22.343
data regarding AKI after PCNL surgery, and the
incidence herein is reported to vary from 11% to
1 Senior resident, Department of Anesthesiology & Critical Care, University College of Medical Sciences &
GTB Hospital, 110095, Delhi, India , 2 Assistant Professor, Department of Anesthesiology & Critical Care,,
University College of Medical Sciences & GTB Hospital, 110095, Delhi, India, 3 Director Professor, Department
of Anesthesiology & Critical Care, University College of Medical Sciences & GTB Hospital, 110095, Delhi, India ,
4 Professor, Department of Anesthesiology & Critical Care, University College of Medical Sciences & GTB Hospital,

110095, Delhi, India

Address for correspondence:
Asha Tyagi, Director Professor, Department of Anesthesiology & Critical Care, University College of Medical Sciences & GTB
Hospital, 110095, Delhi, India . E-mail: drashatyagi@gmail.com

Journal of Medical Sciences and Health/Jan-April 2023/Volume 9/Issue 1 1

Mohan, et al: Stroke volume variation
16.2%, being higher in those with solitary kidney
(25%). [2,4,5]
The risk of postoperative AKI depends upon the
patient’s general condition and ability to respond
to physiologic/pathologic changes brought on by
surgery. [6] Intraoperative hypotension is a known
risk factor for AKI following PCNL surgery. [2] Indeed,
hypotension and hypoperfusion are perhaps the
commonest risk factors for perioperative AKI follow-
ing any type of surgery. To prevent intraoperative
hypotension, optimization of intravascular status
by administering intravenous fluids is a mandatory
anesthetic goal. Conventionally, the volume of
maintenance intravenous fluids to be infused is
calculated according to the rule of 4-2-1, based on
weight of the patient. [7]
A recent alternative approach to determine volume
of intravenous fluid for infusion intraoperatively is
the use of goal directed therapy. [7] Herein, fluids
are administered based on certain physiological
variables or parameters related to the cardiac output
or global oxygen delivery. From among various
variables used to guide fluid infusion during goal
directed therapy, the stroke volume variation (SVV)
is a common and successfully used one. [8,9] It
refers to variations in left ventricular stroke volume
during inspiration versus expiration, occurring due
to intrathoracic pressure changes during intermittent
positive pressure ventilation. Since greater hemo-
dynamic stability is reported by using SVV guided
fluid therapy, [10] it could improve the perioperative
renal function as well. Indeed, in a recent study, the
SVV was seen to be a predictor of postoperative AKI
in patients undergoing abdominal aortic aneurysm
surgery. [11]
There is however no evidence of using SVV targeted
fluid therapy in patients undergoing PCNL surgeries.
Against the above background, the present study
aimed to evaluate and compare postoperative AKI
following intraoperative use of conventional versus
SVV directed fluid therapy, in patients undergoing
PCNL surgery.
Material and Methods
The prospective randomized double-blinded pilot
study was undertaken after getting approval from
the Institutional Ethical Committee-Human Research
(IEC-HR), in its meeting held on 13-10-2018 and
informed written consent from all participating
2 Journal of Medical Sciences and Health/Jan-April 2023/Volume 9/Issue 1
patients. It is prospectively registered with CTRI (Ref.
No. CTRI/2018/12/016693; registered on 17/12/2018).
Adult patients of age between 16 and 65 years
scheduled for PCNL surgery under general anesthesia
were included in the study. Patients receiving renal
replacement therapy or with transplanted kidney; or
clinical evidence of significant dysrhythmia, cardiac
failure, stroke, coronary heart disease (with left
ventricular ejection fraction [LVEF] < 50% where
echocardiography was indicated) were excluded.
Anesthetic Management
In the operating room, monitoring including oscil-
lometric noninvasive blood pressure, lead II elec-
trocardiography, pulse oximetry and capnography
were instituted. An intravenous line was established
and infusion of Ringer’s lactate initiated. Injection
morphine (0.05-0.15 mg/kg i.v.) was given.
For all patients, under local anesthesia, radial
artery cannulation was performed and connected to
VigileoTM system (Edwards Lifesciences, LLC, USA).
This system enabled the continuous monitoring
of stroke volume and cardiac output by pulse
contour analysis, without requirement of external
calibration. The SVV was calculated automatically
by the monitoring system, as the variation of beat-to-
beat stroke volume from the mean value during the
most recent 20 seconds data (SVV = SVmax – SVmin /
SVmean ). Following establishment of optimal arterial
waveform, anesthesia was induced using propofol (1-
2.5 mg/kg i.v.) followed by vecuronium (0.1 mg/kg
i.v.) to facilitate endotracheal intubation. Mechanical
ventilation was initiated using tidal volume of 8
ml/kg ideal body weight, and respiratory rate of 10 per
minute titrated to maintain end tidal carbon dioxide
level of 30 to 40 mmHg. Anesthesia was maintained
using isoflurane along with nitrous oxide, along
with inspired oxygen concentration of 0.3 titrated
intraoperatively to maintain SpO2 ≥ 95%. At the
end of surgery, residual neuromuscular blockade was
reversed with glycopyrrolate (0.01 mg/kg i.v.) and
neostigmine (0.05 mg/kg i.v.). Blood transfusion was
used if blood loss exceeded estimated maximum
allowable blood loss for a target hemoglobin of ≥ 8
g/dl.
Intervention as per group allocation (Fluid
regimen)
A computer-generated random number table was
used for randomizing the patients to receive intra-
operative intravenous fluids guided by SVV (Group
Mohan, et al: Stroke volume variation
S) or as per Conventional estimation (Group C).
The patient, and the anesthesiologist evaluating for
postoperative AKI were not aware of the group
allocation, making this a double-blinded trial.
In group C, the fasting deficits and maintenance
volumes were calculated using the 4-2-1 estimation
of maintenance water requirements and Ringer’s Lac-
tate infused accordingly. [7] Additionally, hypoten-
sion was treated with boluses of 100 ml Ringer’s
lactate till the mean arterial pressure increased above
the hypotensive value (i.e., calculated as fall beyond
20% from baseline).
In group S, whenever the SVV was > 10% in supine
position; or > 14% in prone position, a bolus of
minimum 100 ml Ringer’s lactate was infused over
2 to 4 minutes. Fluid boluses were repeated every 5
minutes till SVV criteria was met. In case of failure of
any response to the bolus fluid, the wait period of 5
minutes was not be adhered to. Unless accompanied
by hemodynamic instability, SVV variations were
treated only if sustainable for at least 2-3 minutes. In
addition, a baseline infusion of 1ml/kg/hr of Ringer’s
Lactate was continued in Group S. In both groups,
use of vasopressor bolus was left to discretion of the
attending anesthesiologist
Operational definitions and concerned procedures
We followed up patients for incidence of early post-
operative AKI (that is up to 48 hours postoperatively)
as the primary outcome measure; severity of AKI, as
well as postoperative changes at 24 and 48 hours in
serum creatinine and estimated glomerular filtration
rate.
AKI was defined as per the KDIGO guidelines ie;
an increase in serum creatinine of ≥ 0.3 mg/dl
above baseline within 48 hours or an increase to
≥ 1.5 times baseline which is known or presumed
to have occurred within the prior 7 days; or urine
output of < 0.5 ml/kg/hr for 6 hours. [12] The severity
was graded as per level of derangement of serum
creatinine or urine output. [12] For evaluation of the
above outcome measures, baseline serum creatinine
value prior to surgery was noted, and it was repeated
on the first two postoperative days. Urine output was
also to be considered for diagnosis of postoperative
AKI in addition to serum creatinine if estimates of
hourly collection would be available. The estimated
glomerular filtration rate was calculated using the
MDRD equation wherein, (18) eGFR = 186 x [serum
Cr (mg/dl)]-1.154 × (age)-0.203 × 0.742(for females) ×
Journal of Medical Sciences and Health/Jan-April 2023/Volume 9/Issue 1
1.210 (for blacks).
Ancillary observations
Other observations included demographic parame-
ters viz., age, height, weight, body mass index and
gender; surgical details such as duration of surgery,
volume of irrigation fluid, and any complications
thereof; efficacy of intravascular volume mainte-
nance shown by volume of intraoperative Ringer’s
lactate, incidence of hypotension (> 20% fall in mean
arterial pressure), usage of vasopressor (mephen-
termine 3mg intravenous) boluses, intraoperative
hemodynamic parameters such as cardiac index,
SVV, invasive mean arterial pressure and heart rate;
and other risk factors of renal dysfunction such as
preexisting diabetes mellitus, hypertension, chronic
obstructive pulmonary disease, obesity, nephrotoxic
drugs including contrast media.
To record the intraoperative hemodynamic stability,
the heart rate, invasive mean arterial pressure and
cardiac index were recorded prior to induction of
anesthesia (baseline), after intubation and initiation
of mechanical ventilation, after change of position,
followed by every 15-minute intervals till end of
surgery and after any change in position. SVV was
also recorded at all the above time points except prior
to induction of anesthesia since mechanical ventila-
tion is an essential prerequisite for its measurement.
The baseline for SVV was accordingly the value
just after intubation and initiation of mechanical
ventilation.
Other postoperative outcome measures including
postoperative duration of hospital stay, and the
preoperative as well as postoperative hemoglobin
were also recorded.
Statistical Analysis
Statistical analysis was done using the software
SPSS version 23.0. Distribution of quantitative data
was checked for normality using K-S test. Normally
distributed data is presented as mean ± standard
deviation and non-normally distributed data as
median [IQR]. Intergroup comparison for qualitative
data was done using chi-square or Fischer’s exact test,
Mann-Whitney U test for non-normally distributed
quantitative data, and t-test for normally distributed
quantitative data. For intergroup comparison of
repeated measures, general linear model of ANOVA
or Mann-Whitney U test with Bonferroni correction
was used for normal and non-normal distribution. P
value < 0.05 was considered statistically significant.
3
Mohan, et al: Stroke volume variation
We carried out intention-to-treat analysis. This
implied analyzing the outcomes and data of patients
in whom intraoperative decision to carry out only
URS + DJ stenting was made instead of PCNL (n=2 in
each group).The intraoperative duration over which
all repeated hemodynamic parameters were recorded
ranged up to 105 and 120 minutes respectively
for group C and group S. For statistical analysis
and comparison of the repeated hemodynamic
parameters, the readings for up to 30 minutes after
prone positioning were included. This was done
consequent to completion of surgery by this time in
most cases.
Sample Size
Considering an earlier incidence of postoperative
AKI following PCNL surgery (11%), 87 patients are
required in each group to detect a fall in incidence to
1%, at significance level of 5%. The present results
are from 32 patients constituting a randomized pilot
study. Since this was a pilot study, we had planned
to recruit 20 patients in each group. However,
consequent to COVID induced disruption of non-
COVID care in our hospital, only 32 could be enrolled
in the specified duration of the study. Thus we are
presenting the results for 32 as a pilot study.
Results
Out of the total 33 patients assessed for eligibility, 1
patient who was receiving renal replacement therapy
was excluded (Figure 1). Total of 32 patients were
randomized into 2 groups, Group C and Group S,
with 15 and 17 patients in each group respectively
and received intervention. None of the patients were
lost to follow up.
Figure 1: CONSORT Flow Diagram
4 Journal of Medical Sciences and Health/Jan-April 2023/Volume 9/Issue 1
The baseline characteristics for both groups were
statistically similar (P > 0.05, 95% Confidence
Interval) (Table 1). The incidence of various systemic
co-morbidities in group C and group S was as follows:
hypertension (2 versus 4), diabetes mellitus (0 versus
2), hypothyroidism (1 each), obesity (i.e., BMI > 30
kg/m2 ) (0 versus 1) and human immunodeficiency
virus infection (0 versus 1) respectively. More than
1 co-morbidity was present in some patients.
Incidence of early postoperative AKI (within 48
hours postoperatively) was clinically higher, but
statistically similar, for group S as compared to
group C (8/17 = 47.1% versus 4/15 = 26.7%) (P
= 0.234, 95% Confidence Interval). The diagnosis
of postoperative AKI is based on changes in serum
creatinine as per the KDIGO guidelines.
The distribution of patients according to severity
of AKI was also statistically similar between both
groups (P = 0.312, 95% Confidence Interval). From
among those who developed AKI, the percentage of
patients in group C and group S with grade 1 AKI was
3/4 (75%) and 7/8 (87.5%); and for grade 2: 1/4 (25%)
and 1/8 (12.5%). None of the patients developed
grade 3 AKI.
The postoperative change in serum creatinine and
estimated glomerular filtration rate (eGFR), on 1st as
well as 2nd postoperative day, were also statistically
similar between group C and group S (P > 0.05)
(Table 2). However, the increase in eGFR and 24-
hour urine output were clinically greater on first
postoperative day for group S (Table 2). Although the
hourly estimates of postoperative urine output were
not available, the 24-hour volumes were noted and
found to be statistically similar between both groups
(Table 2).
Volume of intraoperative fluids was significantly
higher for group C versus group S (P = 0.000,
95% Confidence Interval) (Table 3). Despite this,
the need of vasopressor was significantly greater
and hypotension (defined as fall in mean arterial
presure by >20% from baseline) was clinically
higher, though statistically similar for group C versus
group S (P = 0.659) (Table 3). The serum lactate
remained statistically similar between both groups
prior to induction and at the end of surgery (P> 0.05)
(Table 3).
The hemoglobin level was similar between group
C and group S on each of pre-defined times i.e.,
Mohan, et al: Stroke volume variation

Table 1: Comparison of baseline characteristics

Characteristic Group C (n = 15) Group S (n = 17) P SMD or median differ-
value ence or RR (95% CI)
Age (years) 38.4 ± 12.9 34.4 ± 12.9 0.389 -0.31 (-1.033 to 0.414)
Gender (Male : Female) 9:6 10 : 7 0.787 0.98 (0.552 to 1.74)
Height (cm) 160.3 ± 9.4 161.2 ± 7.9 0.745 0.097 (-0.627 to 0.82)
Weight (kg) 60 [45-68] 60 [42.5-71.5] 0.910 0 (-14 to 14)
Body mass index (kg/m2 ) 22.6 ± 4.0 22 ± 4.7 0.695 -0.132 (-0.855 to 0.592)
Ideal body weight (kg) 55.4 ± 10.5 56.1 ± 9.1 0.840 0.071 (-0.652 to 0.795)
Heart rate (/min) 91 ± 18 95 ± 14 0.505 0.239 (-0.484 to 0.963)
Mean arterial pressure (mmHg) 104 [90-108] 100 [93-111] 0.545 3 (-8 to 19)
Oxyhemoglobin saturation (%) 100 [99-100] 100 [100-100] 0.465 0 (0 to 0)
Preoperative hemoglobin (gm/dl) 12.0 ± 1.9 12.5 ± 2.3 0.463 0.264 (-0.46 to 0.987)
Maximum allowable blood loss (ml) 1254 ± 659 1397 ± 793 0.588 0.194 (-0.529 to 0.917)
Presence of systemic co-morbidities 4 (26.6) 5 (29.4) 1 1.103 (0.361 to 3.369)
Values are mean ± SD or median [IQR] or number of patients (%), SMD-Standardised mean difference, Median difference- Hodges-
Lehmann estimation, RR-Relative risk

Table 2: Postoperative changes in serum creatinine and estimated glomerular filtration rate
Characteristic Group C (n = 15) Group S (n = 17) P value Median difference
(95% CI)
Change in serum creatinine (POD1) (%) -10 [-15 to 5] -10 [-20 to 15] 0.986 0 (-30 to 20)
Change in serum creatinine (POD2) (%) -10 [-20 to 10] -10 [-20 to 20] 0.986 0 (-30 to 20)
Change in eGFR (POD1) (%) 0 [-18 – 0] 13 [-24 – 0] 0.994 -3.6 (-17.9 to 15.1)
Change in eGFR (POD2) (%) -13 [-17 – 0] -11 [-29 – 6] 0.851 0 (-21.9 to 25.6)
Urine output (1st postoperative day) 1400 [1000-2050] 1900 [950-2400] 0.198* 200 (-500 to 900)
(ml/day)
Urine output (2nd postoperative day) 1900 [1450-2000] 1900 [1250-2635] 170 (-600 to 1100)
(ml/day)
Values are median [IQR]; eGFR = estimated glomerular filtration rate; Median difference- Hodges-Lehmann estimation; POD =
postoperative day.
* Value obtained with Mann-Whitney U test, significance at P < 0.017 after being adjusted for Bonferroni correction due to the repeated
measurements.

Table 3: Comparison of parameters related to efficacy of intravenous fluid management

Characteristic Group C (n = 15) Group S (n = 17) P value* SMD or median differ-
ence or RR (95% CI)
Intraoperative fluid infused (ml) 1700 [1425-1700] 332[198 – 660] 0.000 -1256(-1473 to -956)
Intraoperative vasopressor usage 7 (46.7) 0 (0) 0.002 0.059(0.004to 0.957)
Intraoperative hypotension 13 (86.7) 13 (76.5) 0.659 0.882(0.634 to 1.227)
Serum lactate (pre-induction) 1.3 ± 0.6 1.1 ± 0.6 0.155* -0.453(-1.358 to 0.451)
(mmol/l)
Serum lactate (end of surgery) 1.4 ± 0.3 1.2 ± 0.6 -0.278(-1.182 to 0.627)
(mmol/l)
Values are mean ± SD or number of patients (%) or median [IQR], SMD-Standardised mean difference, Median difference- Hodges-
Lehmann estimation, RR-Relative risk.
* P-value for inter-group comparison using the repeated measure ANOVA test.

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Mohan, et al: Stroke volume variation
preoperatively, postoperative day 1, as well as on
postoperative day 2: 12.0 ± 1.9 versus 12.5 ± 2.3
gm/dl; 10.5 ± 1.6 versus 11.2 ± 2.0 gm/dl; and 10.6 ±
1.7 versus 11.3 ± 2.0 gm/dl respectively. (P = 0.338).
An intergroup comparison showed similar SVV in
both groups at each of the predefined time points (P
= 0.141), although it was clinically lower for group C
as compared to group S (Figure 2). However, the SVV
remained above threshold value of 10% in supine
position and 14% in prone position on all times. The
mean heart rate, invasive blood pressure as well as
cardiac index were statistically similar between both
groups at all observed time points (P = 0.150, 0.524
and 0.816 respectively) (Figures 3 and 4).
Figure 2: Intergroup comparison of trend of intraoperative
heart rate
Figure 3: Intergroup comparison of trend of invasive mean
arterial pressure
The surgical characteristics are represented in
Table 4. Duration of surgery and volume of irrigation
fluid were similar between both groups (P > 0.05).
An intraoperative change of surgical plan to forgo
the PCNL after URS with DJ stenting was made in
2 patients of each group (P = 1.000). Number of
patients requiring multiple tracts during PCNL, and
those with single functioning kidney preoperatively
6 Journal of Medical Sciences and Health/Jan-April 2023/Volume 9/Issue 1
Figure 4: Intergroup comparison of trend of stroke volume
variation (SVV)
was statistically similar between both groups (P>
0.05) (Table 4). None of the patients in either
group had intraoperative hemorrhage, required blood
transfusion, or developed a pneumothorax (Table 4).
The electrolyte (serum sodium and potassium) as
well as metabolic (pH, serum HCO3, and PaCO2)
parameters were similar between group C and group
S prior to induction as well as at the end of surgery
(P > 0.05, 95% Confidence Interval) (Table 5).
Discussion
This randomized controlled pilot study aimed to
evaluate and compare early postoperative AKI in
patients undergoing PCNL surgery, following intra-
operative use of conventional versus SVV directed
fluid therapy. It was a pilot study, and there appears
to be a clinical trend of greater incidence of AKI
with use of SVV guided therapy despite better
intraoperative hemodynamic stability and greater
improvement in postoperative urine output and
eGFR in the first postoperative day (P > 0.05).
The incidence of postoperative AKI in the control
group was 26.7%, wherein conventional intraopera-
tive fluid therapy was used. Previous studies noting
postoperative AKI following PCNL surgery are few
in number. [2,4,5] Herein the incidence was noted to
be 11%, [5] 16.2%, [2] and 25% [4] respectively, albeit
without any mention of intraoperative fluid therapy.
Thus, our observed incidence of postoperative AKI
in the control group (26.7%) is similar to the
previously reported figure of 25%. [4] Postoperative
AKI was seen in 47.1% patients of our treatment
group, wherein SVV guided intraoperative fluid
therapy was used. We could not locate any previous
evidence evaluating intraoperative SVV guided fluid
Mohan, et al: Stroke volume variation

Table 4: Surgical characteristics

Characteristic Group C (n = 15) Group S (n = 17) P value SMD or RR (95% CI)
Duration of surgery (mins) 123 ± 41 115 ± 29 0.512 -0.235(-0.958 to 0.489)
Volume of irrigation fluid (L) 11.6 ± 6.6 10.1 ± 5.9 0.510 -0.236(-0.959 to 0.487)
Intraoperative change of surgical plan 2 (13.3) 2 (12) 1.000 0.882(0.141 to 5.516)
Multiple tracts 3 (20) 0 (0) 0.092 0.127(0.007 to 2.275)
Single functioning kidney 0 (0) 2 (12) 0.486 4.44(0.230 to 85.84)
Values are number of patients (%) or mean ± SD, SMD-Standardised mean difference, RR-Relative risk

Table 5: Comparison of electrolyte and metabolic balance

Characteristic Group C (n = 15) Group S (n = 17) P value SMD (95% CI)
Serum sodium (pre-induction) 139.1 ± 6.7 140.4 ± 7.6 0. 719* 0.156 (-0.567 to 0.88)
(mmol/l)
Serum sodium (end of surgery) 144.7 ± 9.5 145.0 ± 10.6 -0.025 (-0.748 to 0.699)
(mmol/l)
Serum potassium (pre-induction) 3.6 ± 0.5 3.5 ± 0.5 0. 223* 0.003 (-0.721 to 0.726)
(mmol/l)
Serum potassium (end of surgery) 3.7 ± 0.5 3.4 ± 0.5 -0.677 (-1.4 to 0.047)
(mmol/l)
pH (pre-induction) 7.39 ± 0.06 7.39 ± 0.04 0.359* -0.077 (-0.8 to 0.647)
pH (end of surgery) 7.37 ± 0.10 7.33 ± 0.08 -0.497 (-1.221 to 0.226)
HCO3 (pre-induction) (mmol/l) 19.9 ± 3.8 18.9 ± 2.8 0.759* -0.304 (-1.027 to 0.42)
HCO3 (end of surgery) (mmol/l) 17.9 ± 3.0 18.4 ± 3.2 0.143 (-0.58 to 0.867)
PaCO2 (pre-induction) (mmHg) 33.1 ± 7.7 32.1 ± 4.6 0.867* -0.25 (-1 to 0.499)
PaCO2 (end of surgery) (mmHg) 31.6 ± 12.3 33.3 ± 8.8 0.241 (-0.508 to 0.991)
Values are mean ± SD. * P-value for inter-group comparison using the repeated measure ANOVA test, SMD-Standardised mean
difference.

therapy for effect on postoperative AKI. There
is however some earlier data during non-PCNL
surgery, showing decreased renal complications and
increased urine output following intraoperative SVV
directed fluid therapy. [10,13] Indeed, we also noted
greater improvement in postoperative urine output
and eGFR on the first postoperative day, although it
was not statistically significant. The previous studies
did not evaluate occurrence of AKI per se and hence
the same cannot be compared.
Given the much greater incidence of AKI with
SVV guided therapy, it is tempting to conclude its
detrimental effect on renal function. However, there
are reasons to desist against a conclusive result at
present. Firstly, this is only a pilot study and thus not
adequately powered. Secondly, the higher incidence
of AKI is contradicted by the clinical trends for
better renal function on first postoperative day (urine
output and estimated glomerular filtration rate) as
well as greater intraoperative hemodynamic stability
(lesser hypotension and vasopressor usage) with
the use of SVV guided fluid therapy. Intraoperative
hypotension is well-known to be perhaps the
commonest risk factor for causing perioperative
AKI. [2,12] It is possible then, that the higher incidence
of AKI based on serum creatinine could merely
be a reflection of relatively lower volumes of fluid
therapy used with SVV guided therapy. The role
of serum creatinine for diagnosing AKI is itself
riddled with limitations, though no substitute has
been discovered despite years of research. Lastly,
despite randomization, patients with risk factors
for postoperative AKI were greater in those who
received SVV directed therapy. These associated risk
factors included presence of a single functioning
kidney, preoperative hypertension, diabetes mellitus
and obesity. [2,4,5]
We noted that majority of the patients with postoper-
ative AKI, in either group, had a mild disease (stage
1), with none developing the most severe form (stage

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Mohan, et al: Stroke volume variation
3). Previously, only 1 out of 3 studies evaluating
postoperative AKI following PCNL surgery noted
its severity distribution. [4] Herein, the severity
distribution showed more severe stages of AKI,
probably because the study was conducted solely
in patients with solitary kidney undergoing PCNL
surgery, an independently associated risk factor of
AKI. In our patients, those with solitary functioning
kidney were 0% and 12% among those receiving
conventional/SVV guided fluid therapy respectively.
Thus, our findings suggest a clinical utility of SVV
guided fluid therapy for maintaining hemodynamic
stability during PCNL surgery. Effect of SVV guided
fluid therapy on postoperative renal function how-
ever will need further research, being guided by the
present observations.
We thus recommend that using SVV guided intra-
operative fluid therapy in patients undergoing PCNL
surgery under general anesthesia is feasible and
safe in terms of maintaining fluid balance as well
as hemodynamic stability. The failure of better
intraoperative hemodynamic stability to translate
into greater preservation of renal functions with SVV
directed therapy will need further research.
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How to cite this article: Mohan A, Gulabani M,
Tyagi A, Jakhar J, Kumar M. Stroke Volume Variation
Directed Versus Conventional Fluid Therapy for
Postoperative Acute Kidney Injury after Percutaneous
Nephrolithotomy - A Randomized Pilot Study. J Med
Sci Health 2023; 9(1):1-8
Date of submission: 20.07.2022
Date of review: 22.08.2022
Date of acceptance: 28.09.2022
Date of publication: 01.01.2023